Nephrology practices spend significant resources on treating patients with kidney diseases and conditions. Therefore, it is important for practices to recover reimbursements from Nephrology medical billing efficiently. Here are some specific strategies nephrology providers can implement to maximize payments for the services they deliver.

Use Precise Diagnosis Coding

The diagnosis codes reported on claims must precisely convey each patient's kidney or comorbid medical issues to support reimbursement amounts. General codes may pay less. Nephrologists should document thorough histories and physical findings to support coding professionals in assigning the most accurate ICD-10 codes describing the patient's condition.
Some key codes for nephrology include N18.6 for end stage renal disease, N04.9 for nephritic syndrome, N28.9 for other disorders of kidney and ureter, and E78.0 for disorders of fatty-acid metabolism. Practices should track commonly seen diagnoses and work with coders to choose codes at the highest specificity level, such as including laterality, complications, and other details for bigger effects on payments.

Prepare for Payment Changes

Nephrology payments experience frequent shifts and new policies from Medicare, Medicaid programs, and commercial insurers. Practices must prepare for changes that may affect them. For instance, Medicare implemented bundled payments for some dialysis services that bundled costs like drugs into single payments rather than paying separately.
It is important for practices to proactively review the Medicare Physician Fee Schedule and payer contract amendments. They should create internal processes to update chargemasters, fee schedules and claims coding/billing promptly to adapt. Partnering with a nephrology medical billing service can also help ensure compliance and maximized reimbursements on evolving policies.

Report E/M and MDM Components
Correct level of service coding, such as evaluation and management (E/M) codes, influences payment amounts. The principal component determining E/M level involves medical decision making (MDM), which itself has three key components: number of diagnoses or management options, amount and complexity of data reviewed, and risk of complications from treatment plans.
Nephrologists and their clinical documentation improvement specialists must effectively capture these MDM details in the medical record. Then coders should assign billing codes reflective of the documented MDM level rather than defaulting to lower codes. Accurately representing complexity of care delivered through MDM coding boosts practice reimbursements.

Bill ESRD Monthly Capitation Payment

Dialysis facilities and nephrologists should ensure they submit bills to receive the monthly capitation payment (MCP) for managing End Stage Renal Disease (ESRD) per the Medicare ESRD Prospective Payment System (PPS). The MCP compensates for care coordination activities between dialysis treatments like medication management and educational services.
Nephrologists needs to verify their Medicare ESRD enrollment and report qualifying services on claims using appropriate codes to receive their portion of the bundled payment. Partnerships with experienced Nephrology medical billing agencies can streamline the process and avoid lost revenue opportunities from failing to bill the MCP allocation.

Pursue Non-Dialysis CKD Billing

Patients with advanced chronic kidney disease (CKD) not yet on dialysis still receive complex disease management from nephrologists. Practices should leverage specific CKD-related codes on non-dialysis claims to maximize appropriate reimbursement. Some codes to consider include:
CKD medical nutritional therapy (97140, G0420)
CKD education services (G0421, G0422)
Advanced CKD visits with thorough history/exam (99215)
Moderate/high complexity decision making (99429)
Transitional care management (99495, 99496)
By properly reporting time and activities involved in comprehensive CKD care, practices can recover fair payments to sustainably treat this vulnerable patient population.

Request Pre-Estimates Proactively
In an era of rising out-of-pocket medical costs, patients want more transparency into their financial responsibilities. Nephrologists and billing staff should set up systems to routinely provide pre-estimate options to patients. This allows informed financial counseling on things like deductibles, services not covered and cash rates for uninsured visits.
Pre-estimate requests can help identify estimated network discounts, contracted allowables from major payers, and highlight charitable assistance programs. It gives practices and patients clarity for procedures like kidney biopsies, injections and upcoming bundled dialysis claims. This counsel preempts unpaid bills and drives up collection rates.

Submit Secondary Claims Timely

Many ESRD and kidney patients have multiple sources of insurance that coordinate benefits, like commercial coverage supplementing Medicare. To maximize payments from secondary and tertiary insurers, practices must submit follow-up claims accurately within the payer's timely filing period, usually 30-180 days after primary settlement.
Using a nephrology medical billing service experienced in managing coordination of benefits (COB) can effectively track multiple payer requirements and prevent revenue loss from missing secondary deadlines. Their expertise in navigating COB streams optimizes payments across all patient coverage sources.

Expand Credentialing and Networking
Nephrologists should proactively expand credentialing with additional commercial plans and Medicare Advantage organizations. Having in-network status provides higher allowable payment rates and waives patients' out-of-network costs and balances. It promotes access to care while growing a practice's revenue base.
Practices should work strategically with payers to maintain good contracting relationships and networks over the long run. They may consider partnering with larger systems or medical groups with credentialing/contracting specialists working on their behalf. Outsourcing these functions through Nephrology medical billing experts can also broaden a practice's profile and contracting success.

Conclusion:

Nephrology practices have many opportunities to boost their bottom line by strategically applying targeted billing approaches. However, keeping up with the complexities of accurate coding, submission requirements, policy updates, and credentialing take dedicated time and resources. For practices seeking an optimized solution, partnering with a specialized medical billing firm can help overcome these challenges. DSO Med Plus is a leader in nephrology medical billing services, offering customized solutions and a team of certified coders and billing specialists focused exclusively on renal services reimbursement. Leveraging DSO Med Plus' expertise and technology-driven processes provides nephrologists assurance that best practices are followed to recover maximum amounts. To see how outsourcing Nephrology medical billing to DSO Med Plus can relieve administrative burden and potentially uncover new revenue for your practice, contact their representatives today to learn more. Taking this step may unlock significant financial benefits for sustaining and growing your practice.